Healthcare Provider Details

I. General information

NPI: 1275521312
Provider Name (Legal Business Name): EDMOND MEDINA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

P12 AVE MAGNOLIA
BAYAMON PR
00956-2608
US

IV. Provider business mailing address

ME8 PLAZA 12 URB. MONTE CLARO
BAYAMON PR
00961-4776
US

V. Phone/Fax

Practice location:
  • Phone: 787-785-9282
  • Fax: 787-785-9290
Mailing address:
  • Phone: 787-785-9282
  • Fax: 787-785-9290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number095
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: